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von Mühlenbrock C, Madrid AM, Defilippi C, Defilippi C, Soto L. Diffuse Gastrointestinal Motor Compromise in Patients with Scleroderma: Utility of Minimally Invasive Techniques. Dig Dis Sci 2024; 69:191-199. [PMID: 37982941 DOI: 10.1007/s10620-023-08151-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/09/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Scleroderma is a systemic inflammatory disorder that can compromise the gastrointestinal tract in up to 90% of patients. AIM The purpose of this work is to characterize esophageal, gastric, and intestinal compromise in patients with scleroderma by means of minimally invasive methods and its association with symptoms and severity of their rheumatological condition. METHODS Patients with systemic sclerosis were recruited according to the criteria of the American College of Rheumatology. The study of digestive involvement was carried out on four consecutive days: esophageal manometry was performed on the first day, intestinal manometry on the second day, surface electrogastrography on the third, and hydrogen breath test on the fourth. The Mann-Whitney test was used for quantitative variables and the chi-squared test for categorical variables (p < 0.05). RESULTS A total of 30 patients were included, with an average age of 52.7 years and 93% women. Average disease evolution duration was 6.5 years, 70% with limited variety. Rodnan averaged 12 points, being higher in the diffuse variety. The main symptom was heartburn, followed by abdominal distension, with no differences between subtypes except for diffuse nausea; 80% had intestinal manometric compromise, 76% esophageal manometric compromise, and 30% electrogastrographic compromise. Bacterial overgrowth was evidenced in two-thirds (66%) of the patients, and 23% of the patients had simultaneous esophageal, gastric, and intestinal involvement, which correlated with greater skin involvement but not with gastrointestinal symptoms. CONCLUSIONS Gastrointestinal involvement in patients with scleroderma is frequent and is observed regardless of the symptoms and clinical characteristics of the latter, except for skin involvement.
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Affiliation(s)
- Christian von Mühlenbrock
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile.
- Internal Medicine Department, Gastroenterology Section, Universidad de los Andes, Av San Carlos de Apoquindo 2200, Las Condes, Santiago de Chile, Chile.
| | - Ana María Madrid
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile
| | - Claudia Defilippi
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile
| | - Carlos Defilippi
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile
| | - Lilian Soto
- Rheumatology Section, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile
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Foocharoen C, Kingkaew P, Teerawattananon Y, Mahakkanukrauh A, Suwannaroj S, Manasirisuk W, Chaiyarit J, Sangchan A. Cost-effectiveness of alginic acid in combination with proton pump inhibitor for the treatment of gastroesophageal reflux disease in systemic sclerosis patients. Int J Rheum Dis 2023; 26:2037-2046. [PMID: 37665078 DOI: 10.1111/1756-185x.14868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Systemic sclerosis (SSc) patients often become refractory to proton pump inhibitors (PPI)-a standard treatment for gastroesophageal reflux disease (GERD)-and intolerant to PPI in combination with domperidone. PPI with alginic acid is an alternative treatment option, but alginic acid is costly. OBJECTIVES We compared the costs and effectiveness of alginic acid plus PPI versus standard treatments (PPI with/without antacids as needed and lifestyle modifications) for GERD in SSc patients unsuitable for, or intolerant to, domperidone. METHODS An economic evaluation using the Markov model was conducted among SSc patients aged between 40 and 65 years with GERD, having a partial or non-response to 4 weeks of standard-dose omeprazole (40 mg/day) and being unsuitable for or intolerant to domperidone. Using a societal perspective, we computed the incremental cost-effectiveness ratios (ICERs) in terms of Thai baht (THB) per quality-adjusted life-year (QALY) between a combination of alginic acid plus PPI and standard treatment for GERD. The lifetime time horizon was used. RESULTS The ICER for alginic acid plus PPI versus standard treatments was 377 101 THB/QALY. According to the one-way sensitivity analysis, the cost of alginic acid was the most impactful parameter. If the market prices of alginic acid plus PPI were reduced by 61%, this treatment option would become cost-effective at the willingness-to-pay threshold of 160 000 THB/QALY (34.68 THB/USD data on 25 May 2023). Furthermore, if alginic acid were included in the public health insurance program, the national budget would be increased by 66 313 THB per patient, resulting in an overall budget increase of 5 106 101 to 8 885 942 THB compared with the standard treatment. CONCLUSIONS Alginic acid plus PPI does not represent good value for money compared with the standard treatment among such SSc patients in Thailand unless its price is reduced significantly.
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Affiliation(s)
- Chingching Foocharoen
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pritaporn Kingkaew
- The Health Intervention and Technology Assessment Program (HITAP), Department of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Yot Teerawattananon
- The Health Intervention and Technology Assessment Program (HITAP), Department of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Witsarut Manasirisuk
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Jitjira Chaiyarit
- Department of Statistics, Faculty of Science, Khon Kaen University, Khon Kaen, Thailand
| | - Apichat Sangchan
- Special Medical Center, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Pavic B, Ogorevc M, Boric K, Vukovic D, Saraga-Babic M, Mardesic S. Connexin 37, 40, 43 and Pannexin 1 Expression in the Gastric Mucosa of Patients with Systemic Sclerosis. Biomedicines 2023; 11:2487. [PMID: 37760928 PMCID: PMC10525958 DOI: 10.3390/biomedicines11092487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs. Although its pathogenesis is not fully understood, connexins (Cxs) and pannexins (Panx) could be involved in the process of fibrosis. We analyzed the protein expression of Cx37, Cx40, Cx43, and Panx1 in the gastric mucosa of patients with SSc and healthy volunteers, using immunofluorescence staining. Protein levels of Cx37 were slightly increased, while the levels of Cx40 were significantly decreased in the lamina propria of the gastric mucosa of SSc patients compared to the controls. The changes were proportional to SSc severity, with the most prominent changes found in patients with severe diffuse cutaneous SSc. No differences in Cx43 or Panx1 levels were found between the analyzed groups of samples. The lack of changes in Cx43 expression, which has been previously associated with fibrosis, could be due to the weak expression of Cx43 in the gastric mucosa in general. Further studies on full-thickness gastric biopsies containing muscle layers and animal SSc models are needed to fully elucidate the role of Cxs and Panxs in SSc-associated fibrosis.
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Affiliation(s)
- Berna Pavic
- Renal Unit, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia;
| | - Marin Ogorevc
- Department of Anatomy, Histology and Embryology, University of Split School of Medicine, Šoltanska 2, 21000 Split, Croatia; (M.O.); (M.S.-B.)
| | - Katarina Boric
- Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia;
| | - Dubravka Vukovic
- Department of Dermatovenerology, University Hospital of Split, Šoltanska 1, 21000 Split, Croatia;
| | - Mirna Saraga-Babic
- Department of Anatomy, Histology and Embryology, University of Split School of Medicine, Šoltanska 2, 21000 Split, Croatia; (M.O.); (M.S.-B.)
| | - Snjezana Mardesic
- Department of Anatomy, Histology and Embryology, University of Split School of Medicine, Šoltanska 2, 21000 Split, Croatia; (M.O.); (M.S.-B.)
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Muacevic A, Adler JR, Figueira ER. First Robotic Roux-en-Y Gastric Bypass for the Treatment of Refractory Gastroesophageal Reflux Disease in a Patient With Systemic Sclerosis. Cureus 2023; 15:e33861. [PMID: 36819430 PMCID: PMC9933002 DOI: 10.7759/cureus.33861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
Systemic sclerosis (SSc) is an immune-mediated disease that results in fibrosis of the skin and internal organs. Refractory gastroesophageal reflux disease (GERD) associated with severe esophageal dysmotility is common in SSc patients, and surgical treatment with usual anti-reflux procedures such as fundoplications is associated with dismal symptomatic relief and postoperative dysphagia. We report the first robotic short-limb Roux-en-Y gastric bypass (RYGB) with a short Roux limb for the treatment of GERD in a patient with SSc with intense esophageal dysmotility. The operative time was two hours. The procedure and postoperative course were uneventful. The patient presented complete relief of gastroesophageal reflux symptoms and no postoperative dysphagia in a two-year follow-up. Therefore, short-limb RYGB is a safe and very effective alternative for the treatment of severe GERD in patients with SSc. The robotic surgical platform may have some advantages compared to conventional laparoscopy.
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Liu P, Chai J, Dai L, Chen B, Zhao J, Lu M, Zeng L, Xia Z, Mu R. Development of a Diagnostic Model Focusing on Esophageal Dysmotility in Patients with Systemic Sclerosis. Diagnostics (Basel) 2022; 12:diagnostics12123142. [PMID: 36553149 PMCID: PMC9776849 DOI: 10.3390/diagnostics12123142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Esophageal dysmotility is a common and neglected complication of systemic sclerosis (SSc) associated with poor prognosis, while the assessment remains a challenge. We aimed to develop a diagnostic model for esophageal dysmotility in SSc patients that provides individualized risk estimates. METHODS Seventy-five SSc patients who underwent high-resolution manometry (HRM) were included in the study. Esophageal widest diameter (WED) was measured on a chest CT scan. Esophageal parameters between patients with and without esophageal dysmotility were compared. Multivariate logistic regression analysis and Least Absolute Shrinkage and Selection Operator (LASSO) regression were used to fit the model. The diagnostic model was evaluated by discrimination and calibration. Internal validation was estimated using the enhanced bootstrap method with 1000 repetitions. RESULTS Sixty-one systemic sclerosis patients (81.3%) were diagnosed with esophageal dysmotility according to the Chicago Classification v 3.0. The diagnostic model for evaluating the probability of esophageal dysmotility integrated clinical and imaging features, including disease duration, ILD, and WED. The model displayed good discrimination with an area under the curve (AUC) of 0.923 (95% CI: 0.837-1.000), a Brier score of 0.083, and good calibration. A high AUC value of 0.911 could still be achieved in the internal validation. CONCLUSION The diagnostic model, which combines the disease duration, ILD, and imaging feature (WED), is an effective and noninvasive method for predicting esophageal dysmotility in SSc patients.
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Affiliation(s)
- Peiling Liu
- Department of Rheumatology and Immunology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing 100191, China
| | - Jing Chai
- Department of Rheumatology and Immunology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing 100191, China
| | - Liyi Dai
- Department of Rheumatology and Immunology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing 100191, China
| | - Beidi Chen
- Department of Rheumatology and Immunology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing 100191, China
| | - Jinxia Zhao
- Department of Rheumatology and Immunology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing 100191, China
| | - Ming Lu
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
- Department of Infectious Diseases, Peking University Third Hospital, Beijing 100191, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China
| | - Zhiwei Xia
- Department of Gastroenterology, Peking University Third Hospital, Beijing 100191, China
| | - Rong Mu
- Department of Rheumatology and Immunology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing 100191, China
- Correspondence:
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Yayla ME, Yurteri EU, Torgutalp M, Eroğlu DŞ, Sezer S, Dinçer ABK, Gülöksüz EGA, Yüksel ML, Yılmaz R, Ateş A, Turgay TM, Kınıklı G. Causes of severe infections in patients with systemic sclerosis and associated factors. Turk J Med Sci 2022; 52:1881-1888. [PMID: 36945989 PMCID: PMC10390190 DOI: 10.55730/1300-0144.5535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 10/10/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a chronic systemic disease characterized by vascular damage, autoimmunity, and fibrosis in the skin and internal organs. In this study, we tried to determine the causes of severe infection in patients with SSc and to reveal the factors associated with severe infection. METHODS We retrospectively examined 214 SSc patients between January 2010 and August 2020. Forty-seven patients with at least one severe infection and 167 patients without severe infection were compared. RESULTS A total of 76 episodes of severe infections were detected in 47 (22%) patients. Common infections included pneumonia, infected digital ulcer, urinary tract infections, and osteomyelitis. Female patients had a higher frequency in the group without severe infection (91.6% vs. 80.9%, p = 0.035). Patients with severe infections had a higher frequency of digital ulcers (p < 0.001), cardiac (p = 0.002), and GIS involvement (p < 0.001). In multivariable analysis, digital ulcer presence (OR: 2.849 [1.356-5.898] (p = 0.006) and cardiac involvement (OR: 2.801 [1.248-6.285]) were associated with severe infection. Of the patients with severe infections, 34% had recurrent severe infections. There was no difference in demographic and clinical characteristics between patients with recurrent and nonrecurrent severe infections. DISCUSSION The presence of digital ulcer and cardiac involvement seem to be associated with a severe infection in patients with systemic sclerosis. In patients with cardiac involvement and digital ulcers, more careful attention may be required for the development of severe infections.
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Affiliation(s)
- Müçteba Enes Yayla
- Department of Internal Medicine, Division of Rheumatology, , Ankara Training and Research Hospital, Ankara, Turkey ; Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Emine Uslu Yurteri
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Murat Torgutalp
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Didem Şahin Eroğlu
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Serdar Sezer
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Ayşe Bahar Keleşoğlu Dinçer
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Emine Gözde Aydemir Gülöksüz
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Mehmet Levent Yüksel
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Recep Yılmaz
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Aşkın Ateş
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Tahsin Murat Turgay
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Gülay Kınıklı
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
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Wang CR, Tsai HW. Autoimmune liver diseases in systemic rheumatic diseases. World J Gastroenterol 2022; 28:2527-2545. [PMID: 35949355 PMCID: PMC9254143 DOI: 10.3748/wjg.v28.i23.2527] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/11/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
Systemic rheumatic diseases (SRDs) are chronic, inflammatory, autoimmune disorders with the presence of autoantibodies that may affect any organ or system. Liver dysfunction in SRDs can be associated with prescribed drugs, viral hepatitis, alternative hepatic comorbidities and coexisting autoimmune liver diseases (AILDs), requiring an exclusion of secondary conditions before considering liver involvement. The patterns of overlap diseases depend predominantly on genetic determinants with common susceptible loci widely distributing in both disorders. In AILDs, it is important to identify the overlapping SRDs at an early stage since such a coexistence may influence the disease course and prognosis. Commonly co-occurring SRDs in AILDs are Sjögren syndrome (SS), rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) in autoimmune hepatitis (AIH), and SS, RA or systemic sclerosis in primary biliary cholangitis. Owing to different disease complications and therapies, it is imperative to differentiate between SLE liver involvement and SLE-AIH overlap disease. Therapeutic options can be personalized to control coexisting conditions of liver autoimmunity and rheumatic manifestations in AILD-SRD overlap diseases. The collaboration between hepatologists and rheumatologists can lead to significant advances in managing such a complex scenario. In this review, we provide a comprehensive overview on coexisting AILDs in different SRDs and the therapeutic approach in managing these overlap diseases.
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Affiliation(s)
- Chrong-Reen Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
| | - Hung-Wen Tsai
- Department of Pathology, National Cheng Kung University Hospital, Tainan 70403, Taiwan
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McMahan ZH, Tucker AE, Perin J, Volkmann ER, Kulkarni S, Ziessman HA, Pasricha PJ, Wigley FM. Relationship Between Gastrointestinal Transit, Medsger Gastrointestinal Severity, and University of California-Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 Symptoms in Patients With Systemic Sclerosis. Arthritis Care Res (Hoboken) 2022; 74:442-450. [PMID: 33064934 PMCID: PMC8050123 DOI: 10.1002/acr.24488] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/22/2020] [Accepted: 10/13/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc)-associated gastrointestinal (GI) complications are attributed to a variety of factors, including diet, microbiota dysbiosis, or GI transit abnormalities. Our objective was to examine the contribution of abnormal GI transit to SSc Medsger GI severity scores and/or University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA GIT) 2.0 symptoms. METHODS Patients with SSc and GI symptoms (n = 71) and healthy controls (n = 18) underwent whole gut transit (WGT) scintigraphy to assess transit from the esophagus to the colon. The presence of delayed transit and percent emptying in each GI region were measured. We compared the WGT measurements between categories of the Medsger GI severity score (0-4) and across UCLA GIT 2.0 domains and total score (0-3). RESULTS A total of 88% of patients had >1 abnormal region of the gut on WGT scintigraphy. All patients requiring total parenteral nutrition had delayed small bowel transit, compared to only approximately 11% of patients in other Medsger GI severity groups (P ≤ 0.01). Severe colonic transit delays were more likely in patients with Medsger GI scores of 3 (pseudo-obstruction and/or malabsorption) compared to other Medsger GI groups (P = 0.02). Seventy-percent of these patients had ≤30% colonic emptying at 72 hours. Modest associations were noted between gastroesophageal reflux disease symptoms and delayed esophageal (r = -0.31, P = 0.05) and gastric emptying (r = -0.32, P = 0.05). CONCLUSION These data are important in providing evidence that SSc bowel disease affects transit of GI content and that delay in transit accounts in part for both bowel symptoms and Medsger GI severity. Prospective studies examining the benefit of early therapeutic intervention targeting GI transit abnormalities in patients at high risk for severe GI complications are needed.
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Affiliation(s)
| | - Ana E Tucker
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Jamie Perin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Lazzaroni MG, Crisafulli F, Moschetti L, Semeraro P, Cunha AR, Neto A, Lojacono A, Ramazzotto F, Zanardini C, Zatti S, Airò P, Tincani A, Franceschini F, Andreoli L. Reproductive Issues and Pregnancy Implications in Systemic Sclerosis. Clin Rev Allergy Immunol 2022; 64:321-342. [PMID: 35040084 DOI: 10.1007/s12016-021-08910-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 12/26/2022]
Abstract
Systemic sclerosis (SSc) is a rare systemic autoimmune disease that can influence reproductive health. SSc has a strong female predominance, and the disease onset can occur during fertility age in almost 50% of patients. Preconception counseling, adjustment of treatment, and close surveillance during pregnancy by a multidisciplinary team, are key points to minimize fetal and maternal risks and favor successful pregnancy outcomes. The rates of spontaneous pregnancy losses are comparable to those of the general obstetric population, except for patients with diffuse cutaneous SSc and severe internal organ involvement who may carry a higher risk of abortion. Preterm birth can frequently occur in women with SSc, as it happens in other rheumatic diseases. Overall disease activity generally remains stable during pregnancy, but particular attention should be paid to women with major organ disease, such as renal and cardiopulmonary involvement. Women with such severe involvement should be thoroughly informed about the risks during pregnancy and possibly discouraged from getting pregnant. A high frequency of sexual dysfunction has been described among SSc patients, both in females and in males, and pathogenic mechanisms of SSc may play a fundamental role in determining this impairment. Fertility is overall normal in SSc women, while no studies in the literature have investigated fertility in SSc male patients. Nevertheless, some considerations regarding the impact of some immunosuppressive drugs should be done with male patients, referring to the knowledge gained in other rheumatic diseases.
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Affiliation(s)
- Maria-Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Liala Moschetti
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Paolo Semeraro
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Ana-Rita Cunha
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Agna Neto
- Rheumatology Department, Hospital Central do Funchal, Madeira, Portugal
| | - Andrea Lojacono
- Obstetrics and Gynaecology Unit, ASST Garda Ospedale of Desenzano, Desenzano del Garda, Italy
| | | | - Cristina Zanardini
- Obstetrics and Gynaecology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Sonia Zatti
- Obstetrics and Gynaecology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Paolo Airò
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy.
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Pettersson H, Alexanderson H, Poole JL, Varga J, Regardt M, Russell AM, Salam Y, Jensen K, Mansour J, Frech T, Feghali-Bostwick C, Varjú C, Baldwin N, Heenan M, Fligelstone K, Holmner M, Lammi MR, Scholand MB, Shapiro L, Volkmann ER, Saketkoo LA. Exercise as a multi-modal disease-modifying medicine in systemic sclerosis: An introduction by The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis (G-FoRSS). Best Pract Res Clin Rheumatol 2021; 35:101695. [PMID: 34217607 PMCID: PMC8478716 DOI: 10.1016/j.berh.2021.101695] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Systemic sclerosis (SSc) is a heterogeneous multisystem autoimmune disease whereby its main pathological drivers of disability and damage are vascular injury, inflammatory cell infiltration, and fibrosis. These mechanisms result in diffuse and diverse impairments arising from ischemic circulatory dysfunction leading to painful skin ulceration and calcinosis, neurovascular aberrations hindering gastrointestinal (GI) motility, progressive painful, incapacitating or immobilizing effects of inflammatory and fibrotic effects on the lungs, skin, articular and periarticular structures, and muscle. SSc-related impairments impede routine activities of daily living (ADLs) and disrupt three critical life areas: work, family, social/leisure, and also impact on psychological well-being. Physical activity and exercise are globally recommended; however, for connective tissue diseases, this guidance carries greater impact on inflammatory disease manifestations, recovery, and cardiovascular health. Exercise, through myogenic and vascular phenomena, naturally targets key pathogenic drivers by downregulating multiple inflammatory and fibrotic pathways in serum and tissue, while increasing circulation and vascular repair. G-FoRSS, The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis recognizes the scientific basis of and advocates for education and research of exercise as a systemic and targeted SSc disease-modifying treatment. An overview of biophysiological mechanisms of physical activity and exercise are herein imparted for patients, clinicians, and researchers, and applied to SSc disease mechanisms, manifestations, and impairment. A preliminary guidance on exercise in SSc, a research agenda, and the current state of research and outcome measures are set forth.
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Affiliation(s)
- Henrik Pettersson
- Women's Health and Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Division of Rheumatology, Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Helene Alexanderson
- Women's Health and Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Division of Rheumatology, Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Janet L Poole
- Occupational Therapy Graduate Program, University of New Mexico, Albuquerque, NM, USA
| | - Janos Varga
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Malin Regardt
- Women's Health and Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Department of Occupational Therapy, Karolinska Institutet, Stockholm, Sweden
| | - Anne-Marie Russell
- University of Exeter, College of Medicine and Health, Exeter, UK; National Institute of Health Research, Senior Nurse Research Leader, London, UK
| | - Yasser Salam
- Department of Physical Therapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Kelly Jensen
- Oregon Health and Science University, Portland, OR, USA; New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA
| | - Jennifer Mansour
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA
| | - Tracy Frech
- Vanderbilt University, Division of Rheumatology, Nashville, TN, USA
| | | | - Cecília Varjú
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | | | - Matty Heenan
- Scleroderma Foundation/Pulmonary Hypertension Association, Tucson, AZ, USA
| | - Kim Fligelstone
- Scleroderma & Raynaud Society UK (SRUK), London, UK; Royal Free Hospital, London, UK
| | - Monica Holmner
- The Swedish Rheumatism Association National Association for Systemic Sclerosis, Sweden
| | - Matthew R Lammi
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA
| | - Mary Beth Scholand
- University of Utah, Division of Pulmonary Medicine, Pulmonary Fibrosis Center, Salt Lake City, UT, USA
| | - Lee Shapiro
- Division of Rheumatology, Albany Medical Center, Albany, NY, USA; Steffens Scleroderma Foundation, Albany, NY, USA
| | - Elizabeth R Volkmann
- University of California, David Geffen School of Medicine, UCLA Scleroderma Program and UCLA CTD-ILD Program, Division of Rheumatology, Department of Medicine, Los Angeles, CA, USA
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA.
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11
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Delaney FT, Fenlon HM, Buckley B, Welaratne I, Cronin CG. Multimodality imaging of the gastrointestinal manifestations of scleroderma. Clin Radiol 2021; 76:640-649. [PMID: 34108098 DOI: 10.1016/j.crad.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 04/21/2021] [Indexed: 11/29/2022]
Abstract
Scleroderma is a complex multisystem connective tissue disorder. Early visceral disease, such as gastrointestinal (GI) involvement, is associated with significant morbidity and a poorer prognosis. Prompt diagnosis is crucial to allow disease modifying therapies be initiated early in the course of the disease. The primary underlying pathophysiology in the GI tract is dysmotility, muscular atrophy, and fibrosis, and this is reflected in the imaging features. In this paper, we demonstrate the imaging appearances of involvement of the GI tract and describe the use of advanced imaging with magnetic resonance enterography (MRE). A multimodal imaging approach is required to identify both characteristic features of scleroderma and potential complications. Traditional fluoroscopic contrast (barium) studies are still commonly performed for assessment of the oesophagus. More recent advances in cross-sectional imaging allow for thorough three-dimensional assessment of the entire GI tract. MRE is particularly useful for small bowel evaluation while also allowing "pseudodynamic" functional imaging and concomitant assessment of the other abdominal viscera and structures.
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Affiliation(s)
- F T Delaney
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - H M Fenlon
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - B Buckley
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - I Welaratne
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - C G Cronin
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
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12
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Imaging in Diagnosis of Systemic Sclerosis. J Clin Med 2021; 10:jcm10020248. [PMID: 33445449 PMCID: PMC7827740 DOI: 10.3390/jcm10020248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/28/2020] [Accepted: 01/08/2021] [Indexed: 12/27/2022] Open
Abstract
Systemic sclerosis (SSc) is a connective tissue disease characterized by fibrosis in skin and internal organs, progressive vascular obliteration, and the production of autoantibodies. Diagnostic imaging is irreplaceable in both diagnosing and monitoring patients suffering from systemic sclerosis. In addition to routinely used methods, such as comparative X-ray of the hands or a contrast-enhanced examination of the upper gastrointestinal tract or chest, there is an array of less widespread examinations, with an emphasis on magnetic resonance imaging (MRI) and ultrasonography, not only in the evaluation of the musculoskeletal system. This article will review the various imaging modalities available for SSc imaging and assessment, focusing on their utility as tissue-specific diagnosis and treatment monitoring.
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13
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Wolf M, Montesi SB. Novel Imaging Strategies in Systemic Sclerosis. Curr Rheumatol Rep 2020; 22:57. [PMID: 32785794 DOI: 10.1007/s11926-020-00926-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Imaging modalities such as computed tomography, ultrasound, magnetic resonance imaging, and molecular imaging are being used to evaluate for disease in systemic sclerosis (SSc) patients. Here, we review novel imaging strategies to detect organ and vascular complications of SSc and novel imaging techniques for assessing interstitial lung disease and pulmonary hypertension in other conditions that may have further applicability to SSc. RECENT FINDINGS Imaging techniques can be used to identify disease in the lungs, pulmonary vascular system, heart, skin, vascular tissue, and gastrointestinal tract of SSc patients. These show promise in detecting early disease, many without the use of ionizing radiation. Novel imaging techniques in patients with SSc can be used to detect disease in multiple susceptible organs. These imaging strategies have potential for early disease detection, as well as potential for incorporation into clinical trials to accelerate the development of SSc therapies.
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Affiliation(s)
- Molly Wolf
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02116, USA.,Harvard Medical School, Boston, MA, USA
| | - Sydney B Montesi
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02116, USA. .,Harvard Medical School, Boston, MA, USA.
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14
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Nagaraja V, Matucci-Cerinic M, Furst DE, Kuwana M, Allanore Y, Denton CP, Raghu G, Mclaughlin V, Rao PS, Seibold JR, Pauling JD, Whitfield ML, Khanna D. Current and Future Outlook on Disease Modification and Defining Low Disease Activity in Systemic Sclerosis. Arthritis Rheumatol 2020; 72:1049-1058. [PMID: 32134199 DOI: 10.1002/art.41246] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 02/27/2020] [Indexed: 01/15/2023]
Abstract
Systemic sclerosis (SSc) is an autoimmune rheumatic disease with heterogeneous clinical manifestations and a variable course in which the severity of the pathology dictates the disease prognosis and course. Among autoimmune rheumatic diseases, SSc has the highest mortality rate among all rheumatic diseases, though there are exciting new therapeutic targets that appear to halt the progression of SSc manifestations such as skin or lung fibrosis. In selected patients, high-intensity regimens with autologous stem cell transplantation can favorably modify the course. In what was once thought to be an untreatable disease, targeted therapies have now changed the outlook of SSc to a treatable disorder. Herein, we discuss the targeted therapies modifying the outlook on selected organ involvement and creating opportunities for future treatment. We also present a framework for defining low disease activity in SSc.
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Affiliation(s)
| | | | - Daniel E Furst
- University of California in Los Angeles, University of Washington, Seattle, and University of Florence, Florence, Italy
| | | | - Yannick Allanore
- Paris Descartes University, INSERM U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France
| | | | | | | | | | - James R Seibold
- Scleroderma Research Consultants, LLC, Aiken, South Carolina
| | - John D Pauling
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, Bath, UK
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15
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García-Collinot G, Madrigal-Santillán EO, Martínez-Bencomo MA, Carranza-Muleiro RA, Jara LJ, Vera-Lastra O, Montes-Cortes DH, Medina G, Cruz-Domínguez MP. Effectiveness of Saccharomyces boulardii and Metronidazole for Small Intestinal Bacterial Overgrowth in Systemic Sclerosis. Dig Dis Sci 2020; 65:1134-1143. [PMID: 31549334 DOI: 10.1007/s10620-019-05830-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 09/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Small intestinal bacterial overgrowth (SIBO) affects up to 60% of patients with systemic sclerosis (SSc), and it improves with antibiotics. The addition of probiotics could lead to better results. AIMS To evaluate the efficacy and safety of Saccharomyces boulardii (SB) versus metronidazole (M) versus M + SB for 2 months, to reduce gastrointestinal symptoms and SIBO assessed with hydrogen breath test in SSc. METHODS An open pilot clinical trial performed in forty patients with SIBO and SSc (ACR-EULAR 2013) who signed informed consent. Three groups were assigned: M, SB, and M + SB, for 2 months. Hydrogen was measured in parts per million with a hydrogen breath test to evaluate SIBO. The National Institutes of Health Patient-Reported Outcomes Measurement Information System (NIH-PROMIS) questionnaire was applied to quantify gastrointestinal symptoms with a raw score of eight symptoms. This study is registered in ClinicalTrials.gov with the following ID: NCT03692299. RESULTS Baseline characteristics were similar between groups. The average age was 53.2 ± 9.3 years, and the evolution of SSc was 13.5 (1-34) years. After 2 months of treatment, SIBO was eradicated in 55% of the M + SB group: 33% of SB, and 25% of M. The SB and M + SB groups had decreased diarrhea, abdominal pain, and gas/bloating/flatulence, but M remained unchanged. Reductions in expired hydrogen at 45 to 60 min were as follows: M + SB 48% and 44%, M 18% and 20%, and SB 53% and 60% at the first and second months, respectively (p < 0.01). Adverse effects were epigastric burning and constipation in M (53%) and M + SB (36%), and flatulence/diarrhea in SB (22%). CONCLUSIONS Metronidazole treatment is partially effective in SIBO, but S. boulardii in monotherapy or in combination improves the gastrointestinal outcomes in SSc.
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Affiliation(s)
- Grettel García-Collinot
- Research Division, Clinical Research Training Center, Hospital de Especialidades Centro Medico 'La Raza', Instituto Mexicano del Seguro Social, Mexico City, Mexico
- Postgraduate Section, Escuela Superior de Medicina (ESM), Instituto Politecnico Nacional, Mexico City, Mexico
| | | | - Michel A Martínez-Bencomo
- Research Division, Hospital de Especialidades Centro Medico 'La Raza', Instituto Mexicano del Seguro Social, Seris y Zaachila SN, Colonia La Raza, Azcapotzalco, Mexico City, Mexico
| | - Rosa A Carranza-Muleiro
- Postgraduate Section, Escuela Superior de Medicina (ESM), Instituto Politecnico Nacional, Mexico City, Mexico
- Research Division, Hospital de Especialidades Centro Medico 'La Raza', Instituto Mexicano del Seguro Social, Seris y Zaachila SN, Colonia La Raza, Azcapotzalco, Mexico City, Mexico
| | - Luis J Jara
- Direction of Education and Research, Hospital de Especialidades Centro Medico 'La Raza', Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Olga Vera-Lastra
- Internal Medicine Department, Hospital de Especialidades Centro Medico, 'La Raza', Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Daniel H Montes-Cortes
- Emergency Department, Hospital General Centro Medico 'La Raza', Instituto Mexicano del Seguro Social, Mexico City, Mexico
- Research Division, Hospital Regional '1° de Octubre', (ISSSTE), Mexico City, Mexico
| | - Gabriela Medina
- Translational Research Unit, Hospital de Especialidades Centro Medico 'La Raza', Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - María Pilar Cruz-Domínguez
- Research Division, Hospital de Especialidades Centro Medico 'La Raza', Instituto Mexicano del Seguro Social, Seris y Zaachila SN, Colonia La Raza, Azcapotzalco, Mexico City, Mexico.
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16
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Richard N, Hudson M, Wang M, Gyger G, Proudman S, Stevens W, Nikpour M, Baron M. Severe gastrointestinal disease in very early systemic sclerosis is associated with early mortality. Rheumatology (Oxford) 2020; 58:636-644. [PMID: 30517716 DOI: 10.1093/rheumatology/key350] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 09/23/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To examine the incidence, predictors and outcomes associated with severe gastrointestinal (GI) disease in a large inception SSc cohort. METHODS SSc subjects with <2 years of disease duration were identified from two multicentre cohorts. Severe GI disease was defined as: malabsorption, hyperalimentation, pseudo-obstruction and/or ⩾10% weight loss in association with the use of antibiotics for bacterial overgrowth or oesophageal stricture. Kaplan-Meier, multivariate logistic regression and Cox proportional hazard analyses were performed to determine the cumulative incidence rate, independent clinical correlates and mortality rate associated with severe GI disease. A longitudinal mixed model was used to assess the impact of severe GI disease on the Short Form Health Survey. RESULTS In this inception SSc cohort, the probability of developing severe GI disease was estimated at 9.1% at 2 years and 16.0% at 4 years. In multivariate analysis, severe GI disease was associated with inflammatory myositis (odds ratio 4.68, 95% CI 1.65, 13.24), telangiectasias (odds ratio 2.45, 95% CI 1.19, 5.04) and modified Rodnan skin score (odds ratio 1.03, 95% CI 1.01, 1.07). Severe GI disease was associated with a >2-fold increase in the risk of death (hazard ratio 2.27, 95% CI 1.27, 4.09) and worse health-related quality of life [Short Form Health Survey physical (β = -2.37, P = 0.02) and mental (β = -2.86, P = 0.01) component summary scores]. CONCLUSION Severe GI disease is common in early SSc and is associated with significant morbidity and increased mortality. More research is needed to understand, prevent and mitigate severe GI disease in SSc.
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Affiliation(s)
- Nicolas Richard
- Division of Rheumatology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada.,Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mianbo Wang
- Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Geneviève Gyger
- Department of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne at St Vincent's Hospital, Melbourne, Victoria, Australia
| | | | | | - Murray Baron
- Department of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada.,Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
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17
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Schutyser W, Cruyt L, Vulsteke JB, Lenaerts JL, De Langhe E. The role of high-resolution manometry in the assessment of upper gastrointestinal involvement in systemic sclerosis: a systematic review. Clin Rheumatol 2019; 39:149-157. [PMID: 31709478 DOI: 10.1007/s10067-019-04794-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/11/2022]
Abstract
Systemic sclerosis (SSc) affects the upper gastrointestinal (GI) system in 90% of patients. High-resolution manometry (HRM) assesses esophageal dysmotility, but its role in diagnosis and follow-up remains unclear. The objectives of this systematic review were to investigate the role of HRM in the assessment of SSc-associated upper GI involvement and to evaluate the correlation between HRM abnormalities and clinical characteristics and the effects of therapeutic interventions on HRM findings. Fifteen articles were included. Most (11/15) studies were of very good or good quality. Most studies assessed correlations between esophageal symptoms and esophageal dysmotility. Two studies assessed the effectiveness of buspirone and reported HRM findings. Studies assessing upper GI symptoms using validated questionnaires, such as the University of California Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 or Gastrointestinal Symptoms Severity Index score, found an association between absent contractility on HRM and upper GI symptoms, but even asymptomatic patients often have esophageal body dysmotility on HRM. Esophageal dysmotility positively correlates with the presence of interstitial lung disease on high-resolution computed tomography and reduced diffusion capacity (< 0.8 of predicted value). Trials investigating the effect of buspirone demonstrate both increased lower esophageal sphincter resting pressure and reduced upper GI symptoms. Most studies report on limited patient numbers and retrospective data. Potential bias was minimized using quality appraisal. HRM findings correlate to upper GI symptoms when assessed by validated questionnaires and can detect response to therapy in buspirone trials. Esophageal body dysmotility on HRM positively correlates with the presence of interstitial lung disease. KEY POINTS: • Esophageal body dysmotility on HRM correlates with presence of ILD. • HRM findings seem to correspond to clinical symptom alleviation in interventional trials, but data are still limited. • At present HRM, a procedure with a high negative burden to the patient, offers little to no role in the therapeutic strategy.
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Affiliation(s)
| | | | - Jean-Baptiste Vulsteke
- Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium.,Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
| | - Jan L Lenaerts
- Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Ellen De Langhe
- Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium. .,Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium.
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18
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Clark KE, Etomi O, Ong VH. Systemic sclerosis in pregnancy. Obstet Med 2019; 13:105-111. [PMID: 33093861 DOI: 10.1177/1753495x19878042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/31/2019] [Indexed: 01/08/2023] Open
Abstract
Systemic sclerosis is a rare multisystem connective tissue disease. It predominantly affects women and poses a significant risk to mother and baby during pregnancy if not managed appropriately. The commonest manifestations are skin fibrosis and Raynaud's phenomenon. Subgroups of women have an increased risk of organ involvement, especially interstitial lung disease, pulmonary arterial hypertension and renal crises. Pregnancy increases the risk to the mother, especially those with established organ involvement, but also the development of new organ dysfunction; and risks to the fetus. Optimising these women prior to conception, along with careful management and surveillance during pregnancy, is vital for optimising pregnancy outcome. Women with scleroderma need to be managed in a specialised centre with coordinated care from the multi-disciplinary teams including physicians, obstetricians, anaesthetists, neonatologists and midwives. This review aims to describe the risks associated with systemic sclerosis and pregnancy, with management advice for physicians looking after pregnant women with this chronic condition.
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Affiliation(s)
- Kristina En Clark
- Centre of Rheumatology and Connective Tissue Diseases, UCL Royal Free Medical School, London, UK
| | - Oseme Etomi
- Department of Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Voon H Ong
- Centre of Rheumatology and Connective Tissue Diseases, UCL Royal Free Medical School, London, UK
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19
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Shepherd AI, Costello JT, Bailey SJ, Bishop N, Wadley AJ, Young-Min S, Gilchrist M, Mayes H, White D, Gorczynski P, Saynor ZL, Massey H, Eglin CM. "Beet" the cold: beetroot juice supplementation improves peripheral blood flow, endothelial function, and anti-inflammatory status in individuals with Raynaud's phenomenon. J Appl Physiol (1985) 2019; 127:1478-1490. [PMID: 31343948 DOI: 10.1152/japplphysiol.00292.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Raynaud's phenomenon (RP) is characterized by recurrent transient peripheral vasospasm and lower nitric oxide (NO) bioavailability in the cold. We investigated the effect of nitrate-rich beetroot juice (BJ) supplementation on 1) NO-mediated vasodilation, 2) cutaneous vascular conductance (CVC) and skin temperature (Tsk) following local cooling, and 3) systemic anti-inflammatory status. Following baseline testing, 23 individuals with RP attended four times, in a double-blind, randomized crossover design, following acute and chronic (14 days) BJ and nitrate-depleted beetroot juice (NDBJ) supplementation. Peripheral Tsk and CVC were measured during and after mild hand and foot cooling, and during transdermal delivery of acetylcholine and sodium nitroprusside. Markers of anti-inflammatory status were also measured. Plasma nitrite concentration ([nitrite]) was increased in the BJ conditions (P < 0.001). Compared with the baseline visit, thumb CVC was greater following chronic-BJ (Δ2.0 flux/mmHg, P = 0.02) and chronic-NDBJ (Δ1.45 flux/mmHg, P = 0.01) supplementation; however, no changes in Tsk were observed (P > 0.05). Plasma [interleukin-10] was greater, pan endothelin and systolic and diastolic blood pressure (BP) were reduced, and forearm endothelial function was improved, by both BJ and NDBJ supplementation (P < 0.05). Acute and chronic BJ and NDBJ supplementation improved anti-inflammatory status, endothelial function and blood pressure (BP). CVC following cooling increased post chronic-BJ and chronic-NDBJ supplementation, but no effect on Tsk was observed. The key findings are that beetroot supplementation improves thumb blood flow, improves endothelial function and anti-inflammatory status, and reduces BP in people with Raynaud's.NEW & NOTEWORTHY This is the first study to examine the effect of dietary nitrate supplementation in individuals with Raynaud's phenomenon. The principal novel findings from this study were that both beetroot juice and nitrate-depleted beetroot juice 1) increased blood flow in the thumb following a cold challenge; 2) enhanced endothelium-dependent and -independent vasodilation in the forearm; 3) reduced systolic and diastolic blood pressure, and pan-endothelin concentration; and 4) improved inflammatory status in comparison to baseline.
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Affiliation(s)
- Anthony I Shepherd
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Joseph T Costello
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Stephen J Bailey
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, United Kingdom
| | - Nicolette Bishop
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, United Kingdom.,University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, United Kingdom
| | - Alex J Wadley
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, United Kingdom.,University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, United Kingdom
| | - Steven Young-Min
- Rheumatology Department, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Mark Gilchrist
- University of Exeter Medical School and NIHR Exeter Clinical Research Facility, Royal Devon and Exeter Hospital, Exeter, Devon, United Kingdom
| | - Harry Mayes
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Danny White
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Paul Gorczynski
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Zoe L Saynor
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Heather Massey
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Clare M Eglin
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, United Kingdom
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20
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Dein E, Kuo PL, Hong YS, Hummers LK, Mecoli CA, McMahan ZH. Evaluation of risk factors for pseudo-obstruction in systemic sclerosis. Semin Arthritis Rheum 2019; 49:405-410. [PMID: 31202479 DOI: 10.1016/j.semarthrit.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/03/2019] [Accepted: 05/20/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Although up to 90% of systemic sclerosis (SSc) patients are affected by gastrointestinal (GI) dysmotility, the clinical phenotype of patients with pseudo-obstruction is not well-defined. We sought to identify this phenotype by studying a large cohort of SSc patients with and without pseudo-obstruction. METHODS We performed a retrospective analysis of patients seen at the Johns Hopkins Scleroderma Center between February 2003 and September 2017. All SSc patients had clinical data prospectively collected in a longitudinal database. Cross-sectional analyses were performed comparing autoantibody status and clinical and demographic features of patients with and without pseudo-obstruction. Cox proportional hazards regression was used to identify risk factors for pseudo-obstruction. RESULTS 175 patients with SSc had a history of pseudo-obstruction, and 2,637 SSc patients did not. After adjusting for significant variables from the univariate analysis and potential confounders, the Cox proportional hazards multivariable analysis demonstrated that older age (HR 1.02; 95%CI 1.00-1.04), male sex (HR 1.75; 95%CI 1.42-2.43), diffuse cutaneous disease (HR 2.52; 95%CI 1.59-3.99), myopathy (HR 1.83, 95%CI 1.09-3.08), and opioid use (HR 2.38; 95%CI 1.50-3.78) were predictive of pseudo-obstruction. Autoantibodies to RNA polymerase-3 were negatively associated with pseudo-obstruction (HR 0.34; 95%CI 0.17-0.66). CONCLUSION We identified clinical features associated with pseudo-obstruction in a large US SSc cohort. This study identifies characteristics of patients with SSc who are at a higher risk of developing pseudo-obstruction and suggests that opioids may be a modifiable risk factor. These clinical features may allow for earlier diagnostic evaluation and/or therapeutic intervention for patients at risk for pseudo-obstruction.
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Affiliation(s)
- Eric Dein
- Johns Hopkins University School of Medicine, United States
| | - Pei-Lun Kuo
- Johns Hopkins Bloomberg School of Public Health, United States
| | - Yun Soo Hong
- Johns Hopkins Bloomberg School of Public Health, United States
| | - Laura K Hummers
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 5200, Mason F. Lord Building, Center Tower, Baltimore, MD 21224, United States
| | - Christopher A Mecoli
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 5200, Mason F. Lord Building, Center Tower, Baltimore, MD 21224, United States
| | - Zsuzsanna H McMahan
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 5200, Mason F. Lord Building, Center Tower, Baltimore, MD 21224, United States.
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Chatzinikolaou SL, Quirk B, Murray C, Planche K. Radiological findings in gastrointestinal scleroderma. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 5:21-32. [DOI: 10.1177/2397198319848550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022]
Abstract
Gastrointestinal involvement is the most common visceral organ manifestation in systemic sclerosis. Symptoms from the gastrointestinal tract are very frequent among scleroderma patients and in many cases present a therapeutic challenge. However, gastrointestinal involvement may also be asymptomatic, presenting with complications later in the disease course. Early recognition of gastrointestinal scleroderma is therefore important both for symptomatic control and prevention of complications. Gastrointestinal imaging alongside clinical assessment forms the mainstay of diagnosis. Radiological investigations, traditionally plain radiographs and barium studies, with the more recent advances in computed tomography, magnetic resonance imaging and ultrasound, provide means for accurate evaluation of visceral organ involvement and more effective patient care. Awareness of the characteristic images is important not only for radiologists but also for the treating physicians and gastroenterologists.
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Affiliation(s)
- Stamatia-Lydia Chatzinikolaou
- Department of Gastroenterology, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Royal Free London NHS Foundation Trust, London, UK
| | - Bernadine Quirk
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Charles Murray
- Department of Gastroenterology, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Royal Free London NHS Foundation Trust, London, UK
| | - Katie Planche
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
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An Obstructing Fecal Bezoar in a Patient with Scleroderma with Successful Colonoscopic Disimpaction. ACG Case Rep J 2019; 6:e00059. [PMID: 31616740 PMCID: PMC6658040 DOI: 10.14309/crj.0000000000000059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022] Open
Abstract
Scleroderma (SSc) is a disease caused by collagen deposition resulting in fibrosis within multiple organs, including the gastrointestinal tract, skin, joints, kidneys, lungs, and heart. We report a rare case of a patient with diffuse SSc who presented with a large bowel obstruction from a fecal bezoar impaction. The bezoar was successfully removed using colonoscopy after lavage, cold forceps, balloon dilator, and cap-assisted disimpaction. We demonstrate that patients with SSc are at risk for bezoar formation and true mechanical obstruction in the lower gastrointestinal tract, which may require more aggressive endoscopic treatment if conservative measures fail.
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Ferdowsi N, Huq M, Stevens W, Hudson M, Wang M, Tay T, Burchell JL, Mancuso S, Rabusa C, Sundararajan V, Prior D, Proudman SM, Baron M, Nikpour M. Development and validation of the Scleroderma Clinical Trials Consortium Damage Index (SCTC-DI): a novel instrument to quantify organ damage in systemic sclerosis. Ann Rheum Dis 2019; 78:807-816. [DOI: 10.1136/annrheumdis-2018-214764] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 01/31/2023]
Abstract
ObjectiveWe sought to develop the first Damage Index (DI) in systemic sclerosis (SSc).MethodsThe conceptual definition of ‘damage’ in SSc was determined through consensus by a working group of the Scleroderma Clinical Trials Consortium (SCTC). Systematic literature review and consultation with patient partners and non-rheumatologist experts produced a list of potential items for inclusion in the DI. These steps were used to reduce the items: (1) Expert members of the SCTC (n=331) were invited to rate the appropriateness of each item for inclusion, using a web-based survey. Items with >60% consensus were retained; (2) Using a prospectively acquired Australian cohort data set of 1568 patients, the univariable relationships between the remaining items and the endpoints of mortality and morbidity (Physical Component Summary score of the Short Form 36) were analysed, and items with p<0.10 were retained; (3) using multivariable regression analysis, coefficients were used to determine a weighted score for each item. The DI was externally validated in a Canadian cohort.ResultsNinety-three (28.1%) complete survey responses were analysed; 58 of 83 items were retained. The univariable relationships with death and/or morbidity endpoints were statistically significant for 22 items, with one additional item forced into the multivariable model by experts due to clinical importance, to create a 23-item weighted SCTC DI (SCTC-DI). The SCTC-DI was predictive of morbidity and mortality in the external cohort.ConclusionsThrough the combined use of consensus and data-driven methods, a 23-item SCTC-DI was developed and retrospectively validated.
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van Caam A, Vonk M, van den Hoogen F, van Lent P, van der Kraan P. Unraveling SSc Pathophysiology; The Myofibroblast. Front Immunol 2018; 9:2452. [PMID: 30483246 PMCID: PMC6242950 DOI: 10.3389/fimmu.2018.02452] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 10/04/2018] [Indexed: 12/31/2022] Open
Abstract
Systemic sclerosis (SSc) is a severe auto-immune disease, characterized by vasculopathy and fibrosis of connective tissues. SSc has a high morbidity and mortality and unfortunately no disease modifying therapy is currently available. A key cell in the pathophysiology of SSc is the myofibroblast. Myofibroblasts are fibroblasts with contractile properties that produce a large amount of pro-fibrotic extracellular matrix molecules such as collagen type I. In this narrative review we will discuss the presence, formation, and role of myofibroblasts in SSc, and how these processes are stimulated and mediated by cells of the (innate) immune system such as mast cells and T helper 2 lymphocytes. Furthermore, current novel therapeutic approaches to target myofibroblasts will be highlighted for future perspective.
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Affiliation(s)
- Arjan van Caam
- Experimental Rheumatology, Radboudumc, Nijmegen, Netherlands
| | - Madelon Vonk
- Department of Rheumatology, Radboudumc, Nijmegen, Netherlands
| | | | - Peter van Lent
- Experimental Rheumatology, Radboudumc, Nijmegen, Netherlands
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18F-FDG PET-MRI with T1 MOLLI mapping to detect systemic sclerosis bowel inflammation and fibrosis. Eur J Radiol 2018; 105:289-295. [DOI: 10.1016/j.ejrad.2018.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/11/2018] [Accepted: 06/25/2018] [Indexed: 12/22/2022]
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Alyousef AA, Nihtyanova S, Denton C, Bosoni P, Bellazzi R, Tucker A. Nearest Consensus Clustering Classification to Identify Subclasses and Predict Disease. JOURNAL OF HEALTHCARE INFORMATICS RESEARCH 2018; 2:402-422. [PMID: 30533598 PMCID: PMC6245235 DOI: 10.1007/s41666-018-0029-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 06/10/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
Disease subtyping, which helps to develop personalized treatments, remains a challenge in data analysis because of the many different ways to group patients based upon their data. However, if we can identify subclasses of disease, then it will help to develop better models that are more specific to individuals and should therefore improve prediction and understanding of the underlying characteristics of the disease in question. This paper proposes a new algorithm that integrates consensus clustering methods with classification in order to overcome issues with sample bias. The new algorithm combines K-means with consensus clustering in order build cohort-specific decision trees that improve classification as well as aid the understanding of the underlying differences of the discovered groups. The methods are tested on a real-world freely available breast cancer dataset and data from a London hospital on systemic sclerosis, a rare potentially fatal condition. Results show that "nearest consensus clustering classification" improves the accuracy and the prediction significantly when this algorithm has been compared with competitive similar methods.
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Affiliation(s)
- Awad A. Alyousef
- Department Computer Science, Brunel University London, Uxbridge, UK
| | | | | | | | | | - Allan Tucker
- Department Computer Science, Brunel University London, Uxbridge, UK
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Abstract
Although classification criteria for systemic sclerosis (SSc) do not incorporate gastrointestinal tract (GIT) manifestations often present in this disease, the GIT is the most common internal organ involved. Pathophysiology of GIT involvement is thought to be similar to other organs in SSc with fibroproliferative vascular lesions of small arteries and arterioles, increased production of profibrotic growth factors, and alterations of innate, humoral, and cellular immunity. These processes result in neuropathy progressing to myopathy with eventual fibrosis. Proper diagnostics and therapeutics for SSc-GIT involvement require the treating physician to have an understanding of an integrated approach and potential medication adverse effects.
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Affiliation(s)
- Tracy M Frech
- Department of Internal Medicine, Division of Rheumatology, University of Utah, Salt Lake Veterans Affair Medical Center, Salt Lake City, UT, USA.
| | - Diane Mar
- Department of Internal Medicine, University of Colorado, Denver, 12631 East 17th Avenue, Aurora, CO 80045, USA
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Vettori S, Tolone S, Capocotta D, Chieffo R, Giacco V, Valentini G, Docimo L. Esophageal high-resolution impedance manometry alterations in asymptomatic patients with systemic sclerosis: prevalence, associations with disease features, and prognostic value. Clin Rheumatol 2018; 37:1239-1247. [PMID: 29442260 DOI: 10.1007/s10067-018-4026-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 12/20/2022]
Abstract
This study aims to investigate pre-clinical esophageal involvement in systemic sclerosis (SSc) by high-resolution impedance manometry (HRiM), its associations with disease features including lung involvement, and its predictivity of esophageal symptoms overtime. Charts of 45 asymptomatic (no heartburn/regurgitation/dysphagia) SSc patients (96% females; mean age 46 years) with at least one follow-up (FU) visit and complete clinical, serological, functional, and radiological assessment, including high-resolution computed tomography (HRCT) of the chest and lung function tests, that had undergone esophageal HRiM were retrospectively evaluated. Esophagogastric junction-contractile integral (EGJ-CI) and esophageal body motility, as evaluated by mean distal contractile integral (DCI), were assessed. SSc patients had a normal esophageal motility in 7/45 cases, a defective EGJ-CI in 28, an ineffective esophageal motility (IEM) in 17, and aperistalsis in 12. Defective EGJ-CI was associated with IEM/aperistalsis in 20 cases, while 9 patients had isolated IEM. Defective EGJ-CI and/or IEM/aperistalsis were associated with a diffusing lung capacity for CO < 80% of predicted value (all p < 0.05), while defective EGJ-CI was also associated with interstitial lung disease on HRCT (p = 0.03). Prevalence of any HRiM abnormality was higher in anti-centromere antibody negative patients (all p < 0.05). IEM/aperistalsis independently increased the risk of esophageal symptoms by 2.3-fold (95% CI 1.1-5.7) and was associated with their higher cumulative incidence with respect to patients with other HRiM patterns at FU (χ2 = 4.63; p = 0.03). SSc patients asymptomatic for esophageal involvement can have HRiM abnormalities in up to 84% of cases. A baseline-impaired motility is a risk factor for symptomatic esophageal disease.
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Affiliation(s)
- Serena Vettori
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy.
| | - Salvatore Tolone
- Division of General, Mini-Invasive and Bariatric Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", II Policlinico, Via Pansini 5, 80131, Naples, Italy
| | - Domenico Capocotta
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Rossella Chieffo
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Veronica Giacco
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Gabriele Valentini
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Ludovico Docimo
- Division of General, Mini-Invasive and Bariatric Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", II Policlinico, Via Pansini 5, 80131, Naples, Italy
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Mouthon L, Alami S, Boisard AS, Chaigne B, Hachulla E, Poiraudeau S. Patients' views and needs about systemic sclerosis and its management: a qualitative interview study. BMC Musculoskelet Disord 2017; 18:230. [PMID: 28558820 PMCID: PMC5450385 DOI: 10.1186/s12891-017-1603-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 05/23/2017] [Indexed: 12/16/2022] Open
Abstract
Background Systemic sclerosis (SSc) is a chronic connective-tissue disease responsible for reduced life expectancy, disability and a decreased quality of life. In order to optimize patients-physicians relationship and care strategy we aimed to survey views of patients on SSc and its management to reveal potential hurdles and improve health care strategies. Methods A qualitative study combined semi-structured interviews, focus groups, and a direct observation of an information session was performed between November 2008 and January 2009. Results Twenty-five patients with SSc were included. They encounter difficulties to have a clear representation of their disease. Physical, psychological, and social repercussions of SSc may lead to a psychological distress and different coping strategies, which widely differ among interviewed patients. Patients’ views on their therapeutic journey and the management of their disease highlighted strong expectations about patient-physician relationship. These expectations were numerous, complex and sometimes ambivalent. Patients expected physicians to be human and attentive but also involved in research in the field and to provide psychological and affective support to help them to accept the uncertainty of disease evolution and lack of curative treatment. They also expected more individualized management, improvements in diagnosis and follow-up organization, more efforts in education and information, comprehensive behaviors and support from working colleagues and relatives, and increased funding from the health care system. Conclusions Our results suggest that SSc management could be optimized, particularly with more attention to the patient–practitioner relationship. Patient profiles should be more precisely defined in terms of coping strategies and treatment preferences to propose more individualized options.
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Affiliation(s)
- Luc Mouthon
- Pôle de Médecine Interne, Centre de référence pour les vascularites nécrosantes et la sclérodermie systémique, hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Descartes, Faculté de Médecine, Paris, France. .,Department of Internal Medicine, Cochin Hospital, 27, Rue du Faubourg Saint-Jacques, 75679, Paris Cedex 14, France.
| | | | | | - Benjamin Chaigne
- Pôle de Médecine Interne, Centre de référence pour les vascularites nécrosantes et la sclérodermie systémique, hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Eric Hachulla
- Service de Médecine Interne, Centre de référence pour la sclérodermie systémique, Hôpital Claude Huriez, Université Lille 2, Lille, France
| | - Serge Poiraudeau
- Faculté de Médecine, Service de Médecine Physique et Réadaptation, hôpital Cochin, AP-HP, Université Paris Descartes, Paris, France.,INSERM U1153, INSERM/CNRS Institut Fédératif de Recherche sur le Handicap, Paris, France
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Mejia Otero C, Assassi S, Hudson M, Mayes MD, Estrada-Y-Martin R, Pedroza C, Mills TW, Walker J, Baron M, Stevens W, Proudman SM, Nikpour M, Mehra S, Wang M, Fritzler MJ. Antifibrillarin Antibodies Are Associated with Native North American Ethnicity and Poorer Survival in Systemic Sclerosis. J Rheumatol 2017; 44:799-805. [PMID: 28365584 DOI: 10.3899/jrheum.160574] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the clinical correlates and survival in patients with antifibrillarin antibodies (AFA) in a large international study population consisting of well-characterized systemic sclerosis (SSc) cohorts from Canada, Australia, and the United States. METHODS Baseline clinical data from the prospective cohorts (Canadian Scleroderma Research Group, the Australian Scleroderma Cohort Study, and the American Genetics versus Environment in Scleroderma Outcome Study) were investigated. Clinical variables were harmonized and sera were tested for AFA using a commercially available SSc profile line immunoassay, regardless of the immunofluorescence staining pattern. Association of demographic and clinical features with AFA was investigated by logistic or linear regression. Further, a survival analysis was performed by Cox regression analysis. RESULTS A total of 1506 patients with SSc with complete serological profiles were included in the study. Fifty-two patients (3.5%) had antibodies detected against fibrillarin. Patients of African descent and Native North American ethnicity were more likely to be AFA-positive compared with other ethnicities. After adjustment for demographic factors, diffuse involvement, and intestinal bacterial overgrowth requiring antibiotics, gastrointestinal reflux disease showed a trend for association with AFA. Further, AFA positivity was associated with shorter survival independently of demographic factors and disease type (HR 1.76, 95% CI 1.11-2.79, p = 0.016). CONCLUSION In this large multinational SSc cohort, AFA was associated with Native American ethnicity and was an independent predictor of mortality.
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Marie I, Leroi AM, Gourcerol G, Levesque H, Menard JF, Ducrotte P. Lactose malabsorption in systemic sclerosis. Aliment Pharmacol Ther 2016; 44:1123-1133. [PMID: 27677253 DOI: 10.1111/apt.13810] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 08/01/2016] [Accepted: 09/05/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are no studies on systemic sclerosis (SSc) assessing the relationship between food intake, especially lactose, and gastrointestinal dysfunction. AIM To determine the prevalence of lactose malabsorption, using lactose breath test, in patients with SSc. To evaluate the correlation between lactose malabsorption and gastrointestinal involvement. To predict which SSc patients exhibit lactose malabsorption. METHODS Seventy-seven consecutive Caucasian patients with SSc and 20 control subjects underwent lactose breath test. All patients also completed a questionnaire on digestive symptoms, and a global symptom score (GSS) was calculated. RESULTS The prevalence of lactose malabsorption was higher in SSc patients than in controls (44.3% vs. 10%; P = 0.004). We observed a marked correlation between the presence of lactose malabsorption and: higher values of GSS (P < 0.0001); severe oesophageal (P = 0.018) and small intestinal (P = 0.04) motor disorders; and joint involvement (P = 0.019). Furthermore, in SSc patients with symptomatic lactose malabsorption, the median value of GSS of digestive symptoms was lower after initiation of lactose-free diet (P < 0.0001). CONCLUSIONS Our study underscores the fact that lactose malabsorption often occurs in patients with systemic sclerosis. Furthermore, our findings highlight the fact that lactose breath test is a helpful, noninvasive method, by identifying the group of patients with systemic sclerosis with symptomatic lactose malabsorption that may benefit from a reduction in lactose intake.
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Affiliation(s)
- I Marie
- Department of Internal Medicine, Rouen University Hospital, and INSERM U 905, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France.
| | - A-M Leroi
- Department of Digestive Physiology, Rouen University Hospital, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France
| | - G Gourcerol
- Department of Digestive Physiology, Rouen University Hospital, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France
| | - H Levesque
- Department of Internal Medicine, Rouen University Hospital, and INSERM U 905, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France
| | - J-F Menard
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - P Ducrotte
- Department of Gastroenterology, Rouen University Hospital, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France
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Emmanuel A. Current management of the gastrointestinal complications of systemic sclerosis. Nat Rev Gastroenterol Hepatol 2016; 13:461-72. [PMID: 27381075 DOI: 10.1038/nrgastro.2016.99] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis is a multisystem autoimmune disorder that involves the gastrointestinal tract in more than 90% of patients. This involvement can extend from the mouth to the anus, with the oesophagus and anorectum most frequently affected. Gut complications result in a plethora of presentations that impair oral intake and faecal continence and, consequently, have an adverse effect on patient quality of life, resulting in referral to gastroenterologists. The cornerstones of gastrointestinal symptom management are to optimize symptom relief and monitor for complications, in particular anaemia and malabsorption. Early intervention in patients who develop these complications is critical to minimize disease progression and improve prognosis. In the future, enhanced therapeutic strategies should be developed, based on an ever-improving understanding of the intestinal pathophysiology of systemic sclerosis. This Review describes the most commonly occurring clinical scenarios of gastrointestinal involvement in patients with systemic sclerosis as they present to the gastroenterologist, with recommendations for the suggested assessment protocol and therapy in each situation.
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Affiliation(s)
- Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, UK
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Saigusa S, Inoue Y, Ohi M, Imaoka H, Uratani R, Kobayashi M, Kusunoki M. Distinguishing between limited systemic scleroderma-associated pseudo-obstruction and peritoneal dissemination. Surg Case Rep 2016; 1:21. [PMID: 26943389 PMCID: PMC4747929 DOI: 10.1186/s40792-014-0010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 12/22/2014] [Indexed: 11/10/2022] Open
Abstract
A 78-year-old woman receiving treatment for limited systemic scleroderma (SSc) underwent high anterior resection and partial liver resections for rectosigmoid colon cancer with multiple liver metastases. A year after surgery, an abdominal computed tomography (CT) demonstrated suspicion for peritoneal dissemination with an increase in ascites, and (18)F-fluorodeoxy glucose-positron emission tomography-CT was suggestive of carcinomatosis. We began to decompress the small intestine and administer octreotide. However, the intestinal obstruction did not improve. Although intestinal pseudo-obstruction caused by limited SSc was considered as a differential diagnosis, we performed an exploratory laparotomy because the possibility of peritoneal dissemination-associated obstruction could not be excluded. We observed a moderate amount of serous ascites and dilatation of the small intestine that was white in color, hard, and with limited contractility. There was no evidence of peritoneal dissemination nor of mechanical obstruction. Our experience thus shows the difficulty of distinguishing SSc-associated intestinal pseudo-obstruction from peritoneal dissemination.
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Affiliation(s)
- Susumu Saigusa
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Yasuhiro Inoue
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Masaki Ohi
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Hiroki Imaoka
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Ryo Uratani
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Minako Kobayashi
- Department of Surgery, Wakaba Hospital, 28-13 Minami-Chuo, Tsu, Mie, 514-0832, Japan. .,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
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Marie I, Leroi AM, Gourcerol G, Levesque H, Ménard JF, Ducrotte P. Fructose Malabsorption in Systemic Sclerosis. Medicine (Baltimore) 2015; 94:e1601. [PMID: 26426642 PMCID: PMC4616824 DOI: 10.1097/md.0000000000001601] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 12/11/2022] Open
Abstract
The deleterious effect of fructose, which is increasingly incorporated in many beverages, dairy products, and processed foods, has been described; fructose malabsorption has thus been reported in up to 2.4% of healthy subjects, leading to digestive clinical symptoms (eg, pain, distension, diarrhea). Because digestive involvement is frequent in patients with systemic sclerosis (SSc), we hypothesized that fructose malabsorption could be responsible for intestinal manifestations in these patients. The aims of this prospective study were to: determine the prevalence of fructose malabsorption, in SSc; predict which SSc patients are at risk of developing fructose malabsorption; and assess the outcome of digestive symptoms in SSc patients after initiation of standardized low-fructose diet. Eighty consecutive patients with SSc underwent fructose breath test. All SSc patients also completed a questionnaire on digestive symptoms, and a global symptom score (GSS) was calculated. The prevalence of fructose malabsorption was as high as 40% in SSc patients. We also observed a marked correlation between the presence of fructose malabsorption and: higher values of GSS score of digestive symptoms (P = 0.000004); and absence of delayed gastric emptying (P = 0.007). Furthermore, in SSc patients with fructose malabsorption, the median value of GSS score of digestive symptoms was lower after initiation of standardized low-fructose diet (4 before vs. 1 after; P = 0.0009). Our study underscores that fructose malabsorption often occurs in SSc patients. Our findings are thus relevant for clinical practice, highlighting that fructose breath test is a helpful, noninvasive method by: demonstrating fructose intolerance in patients with SSc; and identifying the group of SSc patients with fructose intolerance who may benefit from low-fructose diet. Interestingly, because the present series also shows that low-fructose diet resulted in a marked decrease of gastrointestinal clinical manifestations in SSc patients with fructose malabsorption, our findings underscore that fructose malabsorption may play a significant role in the onset of gastrointestinal symptoms in these patients. Finally, we suggest that fructose malabsorption may be due to reduced fructose absorption by enterocytes, impaired enteric microbiome, and decreased intestinal permeability.
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Affiliation(s)
- Isabelle Marie
- From the Department of Internal Medicine, CHU Rouen, and INSERM U 905 (IM, HL); Department of Digestive Physiology, CHU Rouen, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research (A-ML, GG); Department of Biostatistics, CHU Rouen (J-FM); and Department of Gastroenterology, CHU Rouen, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France (PD)
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Stanga Z, Aeberhard C, Schärer P, Kocher A, Adler S, Villiger PM. Home parenteral nutrition is beneficial in systemic sclerosis patients with gastrointestinal dysfunction. Scand J Rheumatol 2015; 45:32-35. [PMID: 26303230 DOI: 10.3109/03009742.2015.1064543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To assess 12-month changes in nutritional status and quality of life (QoL) in systemic sclerosis (SSc) patients requiring home parenteral nutrition (HPN). METHOD We conducted a retrospective, single-centre database analysis of SSc patients regarding a 12-month period of HPN at an interdisciplinary University Unit/team for nutrition and rheumatic diseases. Nutritional status was analysed by nutritional risk screening (NRS) and body mass index (BMI). QoL was evaluated using Short-Form Health Survey (SF-36) questionnaires. RESULTS Between 2008 and 2013, daily nocturnal HPN was initiated in five consecutive SSc patients (four females and one male, mean age 62.2 years) suffering severe malnutrition due to gastrointestinal tract (GIT) involvement. After 12 months of HPN, the mean NRS score decreased from 4.4 (range 4-5) to 1.4 (range 1-2), the mean BMI increased from 19.1 (range 17.4-20.3) to 21.0 kg/m2 (range 18.3-23.4). QoL improved in all patients, reflected by the summary of physical components with 33.92 points before vs. 67.72 points after 12 months of HPN, and the summary of mental components with 49.66 points before vs. 89.27 points after 12 months of HPN. Two patients suffered one catheter-related infection each with subsequent surgical removal and reinsertion. CONCLUSIONS HPN is a feasible method for improving anthropometric parameters and QoL in SSc patients severely affected by GIT dysfunction. We recommend HPN in malnourished, catabolic SSc patients unable to otherwise maintain or improve their nutritional status.
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Affiliation(s)
- Z Stanga
- a Department of Endocrinology, Diabetes and Clinical Nutrition , Bern University Hospital and University of Bern , Switzerland
| | - C Aeberhard
- a Department of Endocrinology, Diabetes and Clinical Nutrition , Bern University Hospital and University of Bern , Switzerland
| | - P Schärer
- b Department of Rheumatology, Immunology and Allergology , Bern University Hospital and University of Bern , Switzerland
| | - A Kocher
- b Department of Rheumatology, Immunology and Allergology , Bern University Hospital and University of Bern , Switzerland
| | - S Adler
- b Department of Rheumatology, Immunology and Allergology , Bern University Hospital and University of Bern , Switzerland
| | - P M Villiger
- b Department of Rheumatology, Immunology and Allergology , Bern University Hospital and University of Bern , Switzerland
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Omair MA, Alahmadi A, Johnson SR. Safety and effectiveness of mycophenolate in systemic sclerosis. A systematic review. PLoS One 2015; 10:e0124205. [PMID: 25933090 PMCID: PMC4416724 DOI: 10.1371/journal.pone.0124205] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 03/10/2015] [Indexed: 01/03/2023] Open
Abstract
Background Mycophenolate is increasingly being used in the rheumatic diseases. Its main adverse effects are gastrointestinal, myelosuppression, and infection. These may limit use in systemic sclerosis (SSc) since gastrointestinal involvement is common. The objective of this study is to evaluate gastrointestinal adverse events of mycophenolate in SSc. Secondarily we evaluated other adverse events, and the effectiveness of mycophenolate in skin and lung disease. Methods A literature search of Medline, Embase, Cochrane Central Register of Controlled Trials, and CINAHL (inception-2013) was performed. Studies reporting use of mycophenolate in SSc patients, adverse events, modified Rodnan skin score (MRSS), forced vital capacity (FVC), or diffusing capacity of carbon monoxide (DLCO) were included. The primary outcome was gastrointestinal events occurring after the initiation of mycophenolate. Secondary safety outcomes included myelosuppression, infection, malignancy, and death after the initiation of mycophenolate. Results 617 citations were identified and 21 studies were included. 487 patients were exposed to mycophenolate. The mean disease duration ranged between 0.8-14.1 years. There were 18 deaths and 90 non-lethal adverse events. The non-lethal adverse events included 43 (47.7%) gastrointestinal events, 34 (26%) infections, 6 (5%) cytopenias and 2 (2%) malignancies. The most common gastrointestinal events included diarrhea (n=18 (14%)), nausea (n=12 (9%)), and abdominal pain (n=3 (2%)). The rate of discontinuation ranged between 8%-40%. Seven observational studies reported improvement or stabilization in FVC, and 5 studies report stabilization or improvement in MRSS. Conclusion Mycophenolate-associated gastrointestinal adverse events are common in SSc, but not severe enough to preclude its use. Observational data suggests mycophenolate may be effective in improving or stabilizing interstitial lung disease, and skin involvement.
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Affiliation(s)
- Mohammed A. Omair
- Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Rheumatology, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alahmadi
- Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sindhu R. Johnson
- Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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Park JS, Park MC, Song JJ, Park YB, Lee SK, Lee SW. Application of the 2013 ACR/EULAR classification criteria for systemic sclerosis to patients with Raynaud's phenomenon. Arthritis Res Ther 2015; 17:77. [PMID: 25889905 PMCID: PMC4384278 DOI: 10.1186/s13075-015-0594-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 03/11/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction We investigated how many patients, who presented with Raynaud’s phenomenon (RP) and who had not been classified as systemic sclerosis (SSc), would be reclassified as SSc, if the 2013 American College of Rheumatology (ACR)/the European League Against Rheumatism (EULAR) classification criteria were used. We also analyzed the predictive values of the reclassification as SSc in those patients. Methods We consecutively enrolled 64 patients with RP and 60 patients with SSc. We applied the new classification criteria to them, reclassified them, and compared variables between those who were newly classified as SSc and those who were not or previously classified as SSc. Results Seventeen of 64 patients (26.5%), who presented with RP, but did not fulfill the 1980 ACR classification criteria, were newly classified as SSc by the 2013 ACR/EULAR classification criteria. The newly classified patients as SSc showed increased frequencies of sclerodactyly, digital tip ulcer, telangiectasia, abnormal nailfold capillaries and the presence of anti-centromere antibody, compared to those not and telangiectasia and anti-centromere antibody, compared to the previously classified patients. For the reclassification as SSc, the variables with independent predictive value were sclerodactyly (odds ratio (OR) 60.025), telangiectasia (OR 13.353) and the presence of anti-centromere antibody (OR 11.168). Conclusions Overall, 26.5% of the patients, who presented with RP, but who did not fulfill the 1980 ACR classification criteria, were newly classified as SSc according to the 2013 ACR/EULAR classification criteria. Sclerodactyly, telangiectasia, and the presence of anti-centromere antibody had independent predictive value for reclassifying patients with RP as SSc.
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Affiliation(s)
- Jin-Su Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Min-Chan Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Soo-Kon Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
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Marie I, Leroi AM, Menard JF, Levesque H, Quillard M, Ducrotte P. Fecal calprotectin in systemic sclerosis and review of the literature. Autoimmun Rev 2015; 14:547-54. [PMID: 25661980 DOI: 10.1016/j.autrev.2015.01.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 01/26/2015] [Indexed: 12/14/2022]
Abstract
Fecal calprotectin (FC) is a simple, non-invasive and reproducible test, which has been described to be highly elevated in patients with active inflammatory bowel diseases. Recently, few authors have reported increased levels of FC in SSc patients, although the relationship between FC levels and the degree of gastrointestinal involvement has not yet been determined in patients with SSc. Thus, this prospective study aimed to: 1) determine the prevalence of increased fecal calprotectin (FC) levels in unselected patients with systemic sclerosis (SSc); 2) make prediction about which SSc patients exhibit increased levels of FC; and 3) evaluate the correlation between increased levels of FC and digestive symptoms, and gastrointestinal involvement, including the presence of small intestinal bacterial overgrowth (SIBO) using glucose H2/CH4 breath test. 125 consecutive patients with SSc underwent FC levels and glucose H2/CH4 breath test. All of the patients with SSc also completed a questionnaire on digestive symptoms, and a global symptom score (GSS) was calculated. 93 (74.4%) patients had abnormal levels of FC (>50 μg/g); 68 patients (54.4%) exhibited highly elevated levels of FC (>200 μg/g). A marked correlation was found between abnormal FC levels and GSS score of digestive symptoms, esophageal involvement and delayed gastric emptying. Moreover, we found a strong association between abnormal levels of FC and the presence of SIBO on glucose H2/CH4 breath test, with the higher correlation between the presence of SIBO and the level of FC ≥275 μg/g with an area under the receiver operating characteristic curve of 0.97 ± 0.001 (CI: 0.93-0.99; p<10(-6)); the sensitivity of FC level ≥275 μg/g for predicting SIBO was as high as 0.93, while the specificity was 0.95. Finally, eradication of SIBO was obtained in 52.4% of the SSc patients with a significant improvement of intestinal symptoms. Finally, after 3 months of rotating courses of alternative antibiotic therapy, eradication of SIBO was associated with significant decrease of FC levels in SSc patients. The current study underscores that abnormal FC levels were correlated with gastrointestinal impairment, especially SIBO. Because FC levels ≥275 μg/g were markedly associated with the presence of SIBO, our findings suggest that FC may be a helpful test in identifying the group of SSc patients at high risk for SIBO requiring glucose breath test to detect SIBO. Finally, we also suggest that FC levels may be helpful in SSc patients to assess SIBO eradication, as long-term antibiotic therapy is costly and carries risks such as the onset of pseudo-membranous colitis and SIBO-related antibiotic resistance.
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Affiliation(s)
- I Marie
- Department of Internal Medicine, CHU Rouen, INSERM U 905, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France.
| | - A-M Leroi
- Department of Digestive Physiology, CHU Rouen, INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France
| | - J-F Menard
- Department of Biostatistics, CHU Rouen, Rouen, France
| | - H Levesque
- Department of Internal Medicine, CHU Rouen, INSERM U 905, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France
| | - M Quillard
- Laboratory of Biochemistry, CHU Rouen, Rouen, France
| | - P Ducrotte
- Department of Gastroenterology, CHU Rouen, INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France
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Nagaraja V, McMahan ZH, Getzug T, Khanna D. Management of gastrointestinal involvement in scleroderma. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015; 1:82-105. [PMID: 26005632 DOI: 10.1007/s40674-014-0005-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastrointestinal tract (GIT) commonly affects patients with systemic sclerosis (SSc). The GI involvement is quite heterogeneous varying from asymptomatic disease to significant dysmotility causing complications like malabsorption, weight loss and severe malnutrition. This review focuses on the management of GI involvement in SSc and has been categorized based on the segment of GIT involved. A brief discussion on the role of patient reported outcome measures in SSc-GI involvement has also been incorporated.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | | | - Terri Getzug
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
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Marie I, Antonietti M, Houivet E, Hachulla E, Maunoury V, Bienvenu B, Viennot S, Smail A, Duhaut P, Dupas JL, Dominique S, Hatron PY, Levesque H, Benichou J, Ducrotté P. Gastrointestinal mucosal abnormalities using videocapsule endoscopy in systemic sclerosis. Aliment Pharmacol Ther 2014; 40:189-99. [PMID: 24889779 DOI: 10.1111/apt.12818] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/03/2014] [Accepted: 05/13/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND To date, there are no large studies on videocapsule endoscopy in systemic sclerosis (SSc). Consequently, the prevalence and features of gastrointestinal mucosal abnormalities in SSc have not been determined. AIMS To determine both prevalence and characteristics of gastrointestinal mucosal abnormalities in unselected patients with SSc, using videocapsule endoscopy. To predict which SSc patients are at risk of developing potentially bleeding gastrointestinal vascular mucosal abnormalities. METHODS Videocapsule endoscopy was performed on 50 patients with SSc. RESULTS Prevalence of gastrointestinal mucosal abnormalities was 52%. Potentially bleeding vascular mucosal lesions were predominant, including: watermelon stomach (34.6%), gastric and/or small intestinal telangiectasia (26.9%) and gastric and/or small intestinal angiodysplasia (38.5%). SSc patients with gastrointestinal vascular mucosal lesions more often exhibited: limited cutaneous SSc (P = 0.06), digital ulcers (P = 0.05), higher score of nailfold videocapillaroscopy (P = 0.0009), anaemia (P = 0.02), lower levels of ferritin (P < 0.0001) and anti-centromere antibody. CONCLUSIONS Our study identifies a high frequency of gastrointestinal mucosal abnormalities in SSc, with a marked predominance of vascular mucosal damage. Furthermore, our study shows a strong correlation between gastrointestinal vascular mucosal lesions and presence of severe extra-digestive vasculopathy (digital ulcers and higher nailfold videocapillaroscopy scores). This latter supports the theory that SSc-related diffuse vasculopathy is responsible for both cutaneous and digestive vascular lesions. Therefore, we suggest that nailfold videocapillaroscopy may be a helpful test for managing SSc patients. In fact, nailfold videocapillaroscopy score should be calculated routinely, as it may result in identification of SSc patients at higher risk of developing potentially bleeding gastrointestinal vascular mucosal lesions.
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Affiliation(s)
- I Marie
- Department of Internal Medicine, Rouen University Hospital, Rouen, France
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Abstract
PURPOSE OF REVIEW Gastrointestinal tract (GIT) involvement in systemic sclerosis (scleroderma, SSc) is the most common internal complication. This review discusses the outcome measures to capture GIT involvement in clinical care and trials. RECENT FINDINGS Patient-reported outcome measures have been validated (UCLA Scleroderma Clinical Trial Consortium GIT 2.0 and NIH PROMIS scales) in SSc-GIT. Multiple objective measures are available to assess mucosal involvement and motility in GIT. However, these need to be validated in SSc for trials. SUMMARY GIT is a common cause of morbidity and has negative impact on quality of life in SSc. Recommendations are given for trial design and evaluation of GIT involvement in SSc.
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Ariyasu H, Iwakura H, Yukawa N, Murayama T, Yokode M, Tada H, Yoshimura K, Teramukai S, Ito T, Shimizu A, Yonezawa A, Kangawa K, Mimori T, Akamizu T. Clinical effects of ghrelin on gastrointestinal involvement in patients with systemic sclerosis. Endocr J 2014; 61:735-42. [PMID: 24739333 DOI: 10.1507/endocrj.ej14-0088] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The majority of patients with systemic sclerosis (SSc) have gastrointestinal (GI) tract involvement, but therapies using prokinetic agents are usually unsatisfactory. Ghrelin stimulates gastric motility in healthy human volunteers. In this study, we investigated whether ghrelin could improve gastric emptying in patients with gastrointestinal symptoms due to SSc. The study was performed in a randomized, double-blind, placebo-controlled crossover fashion on two occasions. Ten SSc patients with GI tract involvement received an infusion of either ghrelin (5.0 μg/kg) or saline, and gastric emptying rate was evaluated by ¹³C-acetic acid breath test. Gastric emptying was significantly accelerated by ghrelin infusion in patients with SSc (ghrelin vs. saline: 43.3 ± 11.4 min vs. 53.4 ± 5.4 min, P=0.03). No serious adverse effects were observed. Our results suggest that ghrelin might represent a new therapeutic approach for GI tract involvement in patients with SSc.
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Affiliation(s)
- Hiroyuki Ariyasu
- Ghrelin Research Project, Translational Research Center, Kyoto University Hospital, Kyoto 606-8507, Japan
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Tian XP, Zhang X. Gastrointestinal complications of systemic sclerosis. World J Gastroenterol 2013; 19:7062-7068. [PMID: 24222949 PMCID: PMC3819541 DOI: 10.3748/wjg.v19.i41.7062] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 08/28/2013] [Accepted: 09/05/2013] [Indexed: 02/06/2023] Open
Abstract
Systemic sclerosis is an autoimmune disease characterized by progressive skin thickening and tightness. Pulmonary interstitial fibrosis and kidney damage are the most important indicators for mortality; however, the gastrointestinal tract is the most commonly damaged system. Virtually all parts of the gastrointestinal (GI) tract can be involved, although the esophagus is the most frequently reported. The mechanisms that cause such extensive damage are generally unclear, but vascular changes, immunological abnormalities, excessive accumulation of collagen in the submucosa, smooth muscle atrophy and neuropathy may participate because these are the most common histological findings in biopsies and autopsies. Most patients with GI tract involvement complain about dyspepsia, nausea, vomiting, abdominal bloating/distension, and fecal incontinence. These symptoms are generally mild during the early stage of the disease and are likely ignored by physicians. As the disease becomes more advanced, however, patient quality of life is markedly influenced, whereby malnutrition and shortened survival are the usual consequences. The diagnosis for systemic sclerosis is based on manometry measurements and an endoscopy examination. Supportive and symptomatic treatment is the main therapeutic strategy; however, an early diagnosis is critical for successful management.
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Omair MA, Pagnoux C, McDonald-Blumer H, Johnson SR. Low bone density in systemic sclerosis. A systematic review. J Rheumatol 2013; 40:1881-90. [PMID: 24037552 DOI: 10.3899/jrheum.130032] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The effect of systemic sclerosis (SSc) on bone density is not well understood. Through systematic review of the literature, the objectives of this study were to synthesize data about the prevalence of low bone mineral density (BMD), risk factors for low BMD, and occurrence of fracture and fracture-related mortality in SSc. METHODS A search was conducted of MEDLINE (1948-2012), Evidence Based Medicine Reviews (1991-2012), EMBASE (1980-2012), and CINAHL (1981-2012). Abstracts were screened to identify studies that evaluated low BMD in patients with SSc. Two investigators independently used a standardized form to abstract prevalence of osteopenia and osteoporosis (OP); risk factors for low BMD, BMD measurements, frequency of fracture, and fracture-related mortality. RESULTS Screening of 1032 citations identified 19 articles. Fifteen studies compared patients with SSc to controls. Most patients were white, female (prevalence 74%-100%), and postmenopausal (prevalence 45.9%-100%). The prevalence of low BMD and OP was 27%-53.3% and 3%-51.1%, respectively. Ten studies reported a lower BMD in patients with SSc compared to matched controls, whereas 2 studies reported no difference. Candidate risk factors for low BMD in SSc include family history of OP, age, menopause, diffuse subtype, presence of internal organ involvement, low vitamin D levels, and calcinosis. However, the studies supporting these factors were conflicting. Fracture rate ranged between 0% and 38%. No study reported OP-related fracture mortality. CONCLUSION The data suggest that patients with SSc are at risk of low BMD and fracture, especially when other risk factors for OP are present. The interaction of SSc manifestations, traditional OP risk factors, and clinically relevant outcomes is complex and warrants further research.
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Affiliation(s)
- Mohammed A Omair
- From the Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital; Osteoporosis Program, Toronto General Hospital; Division of Rheumatology, Department of Medicine, Toronto Western Hospital; and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Abstract
Gastrointestinal involvement (GI) is increasingly recognized as a major cause of both morbidity and mortality in systemic sclerosis (SSc). GI complications are common, second only to skin involvement, and affect up to 90% of patients. Although treatment modalities have changed little for upper gut symptoms such as GI reflux, there are emerging treatment modalities for the common lower gut symptoms (constipation and fecal incontinence), which will be reviewed. The important link between reflux and interstitial lung disease in SSc is also addressed. The aim of this review is to help the clinician understand and manage GI symptoms in SSc.
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Affiliation(s)
- Shamaila Butt
- Gastrointestinal Physiology unit, University College Hospital, London, UK.
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Ota Y, Kawaguchi Y, Takagi K, Ichida H, Gono T, Hanaoka M, Higuchi T, Yamanaka H. Ghrelin attenuates collagen production in lesional fibroblasts from patients with systemic sclerosis. Clin Immunol 2013; 147:71-8. [DOI: 10.1016/j.clim.2013.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 12/20/2022]
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Abstract
Systemic sclerosis is a rare autoimmune condition that affects a variety of organ systems. Knowledge of the imaging features in this patient population is essential in facilitating accurate diagnosis and guiding treatment. Common and rare imaging features of systemic sclerosis are reviewed in this article. Skin, musculoskeletal, pulmonary, cardiac, gastrointestinal, renal, and oral imaging are discussed. Conventional radiography, computed tomography of the chest, echocardiography, enterography, scintigraphy, and panorex dental imaging are reviewed. In addition, the evolving applications of ultrasonography and magnetic resonance imaging to evaluate the musculoskeletal and cardiac features of systemic sclerosis are discussed.
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Affiliation(s)
- Russell Chapin
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC 29425, USA.
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Forbess LJ, Gordon JK, Doobay K, Bosworth BP, Lyman S, Davids ML, Spiera RF. Low prevalence of coeliac disease in patients with systemic sclerosis: a cross-sectional study of a registry cohort. Rheumatology (Oxford) 2013; 52:939-43. [PMID: 23335635 DOI: 10.1093/rheumatology/kes390] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES Two prior studies suggested that coeliac disease (CD) has a higher prevalence rate (8%) in SSc than in the general population (1%), but these studies were limited by small numbers and the use of traditional coeliac screening antibody tests, where newer ones with improved accuracy have since emerged. Our aim was to determine the prevalence of CD in a larger SSc population using a more modern serological approach to coeliac testing and to correlate coeliac antibody status with gastrointestinal symptoms. METHODS Stored sera from 72 SSc patients in the Scleroderma Registry at the Hospital for Special Surgery were tested for anti-tissue transglutaminase (traditional) and anti-deamidated gliadin peptide (novel) antibodies. If any of these antibodies were positive, anti-endomysial antibodies were tested and confirmatory small-bowel endoscopy and biopsy were obtained. Registry clinical data were used to determine whether antibody status correlated with gastrointestinal symptoms. RESULTS The prevalence of coeliac antibodies in our SSc population was 3/72 (4%). No significant differences with respect to gastrointestinal symptoms were seen in the coeliac antibody-positive compared with -negative SSc patients. No cases of confirmed CD were seen in our cohort. CONCLUSION Contrary to the only two previously published studies, the low prevalence of CD that we found does not suggest that concurrent CD is a common cause of gastrointestinal complaints in SSc patients.
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Affiliation(s)
- Lindsy J Forbess
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA.
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